What’s the Best Treatment for Pediatric PTSD?

Thole H. Hoppen, Ph.D

Between one- and two-thirds of children and adolescents report exposure to at least one traumatic event. Most are resilient. But about 20% develop pediatric PTSD – more than you might think.

International treatment guidelines recommend trauma-focused cognitive behavior therapies (TF-CBTs). A new synthesis of 70 randomized controlled trials (RCTs) involving 5,528 patients strongly supports those recommendations but also highlighted other treatments that have received far less study and almost none in the long term.

First author Thole H. Hoppen, PhD, a licensed psychotherapist (CBT) and post-doctoral researcher at the Institute of Psychology, University of Münster in Münster, Germany and colleagues from the institute and the United Kingdom, published their findings on Wednesday, Dec. 4, in JAMA Psychiatry.

The researchers wanted to compare outcomes among children ages 19 and under with full or subthreshold PTSD who were treated with various therapies vs. controls categorized as passive (wait-listed) or active (treatment as usual)over short-, medium and long-term periods.

They wrote that that a comprehensive systematic review and network meta-analysis (NMA) was required to measure the relative reductions in pediatric PTSD of all treatment approaches. NMAs This allowed the integration of data from both direct (i.e., comparison of arms within an RCT) and indirect (i.e., comparison of arms across RCTs) comparisons.

Four treatment categories were included in the meta-analysis: 1) TF-CBTs (any CBT-based interventions with a trauma focus, such as prolonged exposure or cognitive processing therapy); 2) eye movement desensitization and reprocessing (EMDR, a relatively new method that involves moving your eyes a specific way while you process traumatic memories); 3) non–trauma-focused interventions (any intervention without a trauma focus); and 4) multidisciplinary treatments (MDTs, defined as treatments that combine techniques from at least two of the other categories, such as the intensive multimodal group program).

A fifth category, for other trauma-focused interventions that are not based on CBT or EMDR principles, such as expressive supportive groups, was planned but lacked comparative data.

TF-CBTs have been studied the most and over the longest periods. The network meta-analysis found that these therapies were associated with significant reductions in symptoms over the short, medium and long term.

Short-term (post-treatment) results of the meta-analysis showed that all the treatment groups — TF-CBTs, EMDR, MDTs and nontrauma-focused interventions — were associated with significantly larger reductions in pediatric PTSD than the passive controls. Only TF-CBTs and non-trauma-focused interventions showed that when compared with active controls. 

In the medium term (up to five months after treatment), TF-CBTs, EMDR and MDTS again showed significantly larger symptom reductions compared with passive controls, while there was not enough comparative data for non-trauma-focused interventions.

In the long term (six to 24 months after treatment), only TF-CBTs and non-trauma-focused interventions had sufficient evidence for comparisons. Both were associated with significantly larger decreases in PTSD symptoms than passive controls – and active (usual care) controls as well.

“These results are important for the training of therapists and implementation in clinical practice and might help in reducing treatment barriers,” wrote Hoppen and his coauthors. But, they concluded, “more high-quality data (including long-term data) are needed to draw firmer conclusions regarding the relative performance of psychological treatments for pediatric PTSD.”